Provider Demographics
NPI:1841442019
Name:VITA PHARMACY LLC
Entity type:Organization
Organization Name:VITA PHARMACY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMEBER
Authorized Official - Prefix:
Authorized Official - First Name:IGOR
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERNYAKOVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-325-1641
Mailing Address - Street 1:5617 BELAIR RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21206-3619
Mailing Address - Country:US
Mailing Address - Phone:410-325-1641
Mailing Address - Fax:410-325-1642
Practice Address - Street 1:5617 BELAIR RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21206-3619
Practice Address - Country:US
Practice Address - Phone:410-325-1641
Practice Address - Fax:410-325-1642
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-18
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336L0003X
MDPW03193336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2134207OtherNCPDP PROVIDER IDENTIFICATION NUMBER